Provider Demographics
NPI:1508902636
Name:PROFESSIONAL PHYSICAL THERAPY PA
Entity Type:Organization
Organization Name:PROFESSIONAL PHYSICAL THERAPY PA
Other - Org Name:PRO PHYSICAL THERAPY PA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:FRICKE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:952-891-2645
Mailing Address - Street 1:27 MARCIN HILL
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337
Mailing Address - Country:US
Mailing Address - Phone:952-891-2645
Mailing Address - Fax:952-997-3410
Practice Address - Street 1:13786 FRONTIER CT
Practice Address - Street 2:#102
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337
Practice Address - Country:US
Practice Address - Phone:952-891-2645
Practice Address - Fax:952-997-3410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2187225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN6407997OtherMEDICA
MN1012293OtherPREFERRED ONE
MN264019500OtherUS DEPT OF LABOR
MN7G667PROtherBCBS OF MN
MN650000561Medicare PIN
MN6407997OtherMEDICA
MNP00151747Medicare ID - Type UnspecifiedRAILROAD MEDICARE